CHAPTER 7 TEACHING POINTS: CONTRACEPTION AND ABORTION AFTERCARE

EXERCISE 7.1

Purpose: To role-play different aspects of contraceptive counseling and to understand recent evidence-based contraceptive developments and medical criteria for use.

1. How would you respond to these common patient concerns about contraception?

• • When talking about side effects or common patient concerns, try to empathize, reassure and normalize the patient’s feelings. Avoid saying things that might invalidate a person’s concerns.
  • Avoid confrontational language. You are not trying to change the patient’s mind, but instead, elicit the patient’s priorities, and understand their goals.
  • Uses phrases like:
    • “Tell me more about that.”
    • “I hear that concern from a lot of patients.”
    • “What worries you the most about that?”
  • Ask for permission to share information: For example, “Can I share some information with you about contraception and abortion?” If the patients give permission, then go on to share facts to help their understanding.

1. I don’t like the idea of having something inside of my body.
   • Thank you for sharing that with me. I have heard that concern from others. It’s normal to be anxious about having something placed inside you;
   • There are methods that don’t have something inside of the body. Would you like to discuss those?
2. I don’t want any hormones.
   • I understand. A lot of people feel that way.
   • What is it about a hormonal method that concerns you?
   • Ok, there are several non-hormonal options we can discuss.
3. Won’t IUDs (or EC pills) cause an abortion?
   • For an abortion to happen, someone has to first be pregnant, and IUDs prevent pregnancy in the first place (by preventing fertilization of an egg, or in the case of hormonal IUDs, by sometimes also preventing the release of an egg.)
   • See evidence that IUD and EC Pills (ECPs) are not abortifacients
   • If the patient is still concerned, consider other options.
4. I want to have this (IUD / implant) removed (a few months after placement).
   • You can absolutely have your method removed today. I am also curious to know more about what is making you want to have the method removed – as there are often things we can do to help manage symptoms, if you like.

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2. A 17-year-old G0 old patient comes to the clinic who is sexually active and currently using withdrawal and condoms. Role-play how you might initiate a conversation about their contraceptive priorities, and options based on a preference of privacy of contraceptive use (from parents) and avoiding STIs?

• • Ask if satisfied with method or wants to discuss others addressing preferences.
  • Discuss effectiveness of withdrawal, and most important cycle times to use condoms.
  • Discuss how and where storage will work to keep condoms, patches, pills or rings.
  • Discuss common changes in menstruation with methods, which can be a signal of a change: DMPA, IUDs, & implants can change heaviness and frequency of periods.
  • Screen for safety at home and in intimate relationship(s) and discuss what they might do for contraceptive failures (i.e. EC, abortion access, etc.)
  • Tell patient that insurance explanation of benefits (EOBs) may be sent to home.
  • Know privacy laws in your state or country regarding reproductive health services, STI testing, and parental notification (Guttmacher 2022)

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3. A 28-year-old G3P3 patient presents to the clinic seeking to switch to a new method of contraception. They are currently on DMPA, which has been causing weight gain, and want something non-hormonal. A friend mentioned having pain with an IUD, so your patient is hesitant to consider that option. Role-play being the healthcare provider and/or patient whose priority is avoiding weight gain and other hormonal side effects.
   • Using the person-centered contraceptive counseling measure, what did you do as a provider to ensure the patient felt respected, listened to, had their preferences identified and received information?
   • As the patient, is there more the provider could have done to establish rapport, identify priorities and share information?

Consider the following principles and steps:

• • Establish and maintain rapport with the patient
  • Assess the patient’s needs and personalize discussions accordingly
    • If the patient has a strong interest in one method, ask permission before providing information on others
    • Consider methods that align with patient priorities (e.g. bleeding changes, frequency of use, privacy, effectiveness, or modality of administration)
  • Work with the patient interactively to establish a plan
    • Anticipate and address barriers to accurate and consistent use of chosen method
  • Provide information that can be understood and retained by the patient
    • Simplify the choice process using visual aids
  • Confirm understanding
    • Use active learning strategies such as teach back

There are many online tools, curriculum and videos to assist learners with contraceptive counseling. Bedsider has excellent videos discussing contraception from the patients’ perspective: https://www.bedsider.org/methods. Watching a few of the videos can help learners appreciate the impact of counseling on patients.

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4. What would you discuss with the following patients regarding their desire for contraception? (Consult MEC as a reference)

• • MEC Category 1 and 2 are both considered safe and OK to proceed with use.
  • MEC Category 3: Discuss risks and use shared decision-making with patient. Consult as needed. Document risk-benefit discussions.
  • MEC Category 4 is considered an absolute contraindication without acceptable use of the method with the specific health condition.

1. 1. A 36-year-old smoker with BMI > 30 who wants the patch.

      • There are two issues to consider:

        • Tobacco users who smoke >15 cigarettes/day and are >35 years old should not use estrogen-containing methods due to increased stroke and M.I. risk (MEC 4
        • BMI > 30 is not considered a contraindication for any birth control (Lopez 2016).
        • This patient could safely use any progestin-only or barrier method.
   2. A 29-year-old with migraine headaches with aura who wants the pill.

      • Avoid estrogen-containing contraceptives in patients with migraines with aura due to increased stroke risk. Use caution with patients with migraines without aura, and consider additional prothrombotic risks (e.g. smoking). These patients are best served with a progestin-only or barrier method. Additional MEC categories include:

        • Migraine with aura or focal neurological symptoms any age (MEC 4).
        • ≥35 years old and migraine without aura (MEC 3).
        • <35 years old and migraine without aura (MEC 2).
        • Non-migraine headaches at any age (MEC 1).

      • Migraine with focal neurological symptoms is equivalent to migraine syndrome with aura (or classic migraine), and consists of one or more of the following that usually precedes and sometimes accompanies the headache:

        • Visual disturbances, scintillating scotoma, aura
        • Paresthesias (numbness and tingling)
        • Hemiparesis (weakness or partial paralysis in an extremity)
        • Dysphasia (slurred speech or inability to speak)
   3. A 20-year-old nulliparous patient with a history of Chlamydia at age 15 and who wants an IUD.
      • IUDs are safe and well accepted among nulliparous patients (MEC 2).
      • Prior concerns about infertility with IUD no longer pertain with modern IUD designs (using monofilament IUD strings). Tubal infertility is linked to presence of Chlamydia antibodies, not to history of IUD use (Hubacher 2001).
      • Return to baseline fertility is almost immediate following IUD removal.
      • Although past studies suggested nulliparous patients have a slightly increased risk of IUD expulsion, a prospective study found no difference in rates of expulsions by parity among CuT users, and lower expulsion rates in nulliparous users of the LNG 52 mcg IUD compared with parous users (Birgisson 2015).
   4. A 28-year-old patient who has BMI > 30, has vaginitis, and wants emergency contraception as well as ongoing contraception. Pt had unprotected intercourse 3 and 5 days ago.
      • CuT IUD & LNG IUD EC are nearly 100% effective, including with BMI > 30. Both provide ongoing contraception, if desired (Turok 2021, Wu 2010).
      • Vaginitis (MEC 2), vs. purulent cervicitis or PID (both MEC 4 for IUD).
      • Vaginitis should not preclude IUD placement; simply initiate treatment today.
      • Patients receiving IUDs for EC were half as likely to become pregnant in the following year compared to oral EC (Turok 2014).
      • Alternatively, consider UPA EC with ongoing contraception as desired.
   5. A 25-year-old with a history of deep vein thrombosis (DVT) 2 years ago, which occurred 6 weeks after a vaginal delivery. They are interested in the vaginal ring.

      • Any patient with a history of a DVT is no longer considered a candidate for estrogen containing birth control, including the vaginal ring. It is important to find out more about the patient’s disease.

        • A postpartum DVT would be considered a pregnancy-associated DVT which is an absolute contraindication (MEC 4).
        • Family history (1st degree relative) is not a contraindication (MEC 2), but someone you should consider testing for thrombophilic conditions.
   6. A 25-year-old transgender man who became amenorrheic on testosterone, wants to prevent pregnancy with a partner that makes sperm.

      • If a patient has a uterus and ovaries, they are capable of becoming pregnant, including TGD people who are taking testosterone and no longer having periods. People taking testosterone can use any method of contraception. Testosterone does not reliably work as contraception, and does not interact with hormones in birth control, although some patients prefer to avoid exogenous estrogen. Some people choose a method to minimize or stop bleeding. As with all patients it is important to discuss the person’s preferences and assess whether there are any contraindications to specific methods.

   7. A 31-year-old who takes anti-seizure medications and wants the pill.
      • Certain anti-seizure medications, antibiotics, and antifungals activate the liver’s p450 enzyme system, resulting in faster metabolism of hormones, and decreased efficacy of combination and progestin-only pills and implants (all MEC category 3 while taking these medications; use shared decision-making; see table below).
      • CHCs may also reduce bioavailability of lamotrigine (Lamictal).
      • Some of these medications may also be used to treat certain psychiatric illnesses, headaches, chronic pain and other conditions.
      • IUDs or DMPA are the safest options (MEC 1 and 2 respectively).
        

        Drugs known to increase liver enzyme metabolism / reduce contraceptive effectiveness	Drugs with questionable effects	Drugs known not to effect liver enzyme metabolism or contraceptive effectiveness
        Carbamazepine (Tegretol, Equetro, Carbetrol) Oxcarbazepine (Trileptal) Phenobarbital Phenytoin (Dilantin) Primidone (Mysoline) Topiramate (Topamax) mild ↓ Rifampin Rifampicin Rifamate Griseofulvin St John’s Wort	Troglitazone (Rezulin) Felbamate (Felbatol)	Lamotrigine (Lamictal) Gabapentin (Neurontin) Tiagabine (Gabitril) Levetiracetam (Keppra) Valproic Acid (Depakote) Zonisamide (Zonegran) Vigabatrin (Sabril) Ethosuximide (Zarontin) Benzodiazepines INH (not in combination with Rifampin) Ketoconazole (anti-fungal) Fluconazole (anti-fungal)

   8. A 27-year-old who wants a combined hormonal method but doesn’t want a monthly period.
      • Extended contraception is safe, acceptable, and as efficacious as monthly cyclic regimens (Edelman 2014).
      • Increased ovarian suppression is noted in regimens that shorten or eliminate the hormone free interval, with the potential for increased effectiveness (London 2016).
      • Regimens result in fewer scheduled bleeding episodes and fewer menstrual symptoms, particularly headache (Edelman 2014).
      • Breakthrough bleeding is common in the first six months of continual use; however this side effect usually resolves within 4-6 months.
      • Extended and continuous use formulations of mono-phasic COCs, and vaginal ring (Annovera or NuvaRing) may be used.
      • Patch is not recommended due to concern over increased levels of estrogen.

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EXERCISE 7.2

Purpose: To review routine follow-up after uterine aspiration, please answer these questions.

1. A patient has had nausea and vomiting throughout pregnancy. How long will it take for them to feel better after the abortion?
   • Nausea is one of the first pregnancy symptoms to subside after an abortion, generally within 24 hours. Nausea may be induced by CHC use.
   • If it persists beyond a week, rule out ongoing pregnancy or retained tissue.
   • Breast tenderness subsides in 1-2 weeks, but may be influenced by CHCs.

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2. Providers typically advise patients to call if they have certain “warning signs” following uterine aspiration. What “warning signs” would you include and why?
   • Persistent severe pain or cramping:
     • May indicate hematometra, infection, uterine trauma, or ectopic.
   • Pelvic / rectal pain with little or no bleeding:
     • Suggests hematometra.
   • Heavy bleeding (saturating >2 pads per hour for >2 hours) or orthostatic symptoms:
     • Suggests the need for intervention.
   • Peritoneal signs (pain with cough, palpation, or sudden movement):
     • May suggest perforation or infection and warrant reevaluation.
   • Sustained fever (greater than 100.4∞F / 38∞C ):
     • Raises concern about pelvic infection.

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3. After an aspiration, how long would you advise your patient to wait before resuming exercise, heavy lifting, and vaginal intercourse? What is the rationale for your recommendations?
   • Resuming exercise or heavy lifting

Many providers empirically discourage strenuous exercise and intercourse for 1-2 weeks after abortion, to prevent exacerbation of bleeding or cramping, or avoid infection, although there is no evidence that this makes any difference.

The patient may resume normal activity when they feel ready, this can be as soon as a few hours after their abortion, or more typically within 24 hours. Probably the best advice is to “listen to your body,” enjoy the activities that make them feel better, and avoid activities that make them worse.

• • Resuming vaginal intercourse

No data suggest increased infection with intercourse after an abortion, so advice may be liberalized. Encourage them to trust their body and resume intercourse when they feel ready. As ovulation can occur within 7-10 days, encourage the patient to initiate their chosen method of contraception promptly after abortion if they do not want to become pregnant at this time.